GBV Staff Referral Form - Student Wellbeing Portal

University of Sydney Student Wellbeing

Gender-based Violence and Other Harmful Behaviour Reporting Form

This form is for University of Sydney staff and affiliates to report gender-based violence, sexual harm or other harmful behaviours.

You can use this form to share your own experience, report another person's experience, or report in your professional capacity as a University staff member, affiliate organisation or third party.

The University acknowledges that submitting a report of gender-based violence, sexual harm or other harmful behaviour can be a confronting experience. The Safer Communities Office staff are available 9am to 5pm Monday to Friday, Sydney local time. You can speak with a team member or make an appointment on the phone by calling +61 2 8627 6808 or emailing safer-communities.officer@sydney.edu.au.

The University has a mental wellbeing support line. If you’re in Australia, you can contact the support line by calling 1300 474 065 or by texting 0488 884 429 outside of office hours (5 pm to 9 am weekdays, 24/7 weekends and public holidays).

For counselling support after-hours, please contact FullStop Australia by calling 1800 424 017. FullStop is a free and confidential service available 24 hours a day, 7 days a week to support people impacted by domestic, family or sexual violence.

About this form

After you submit this form, a member of the Safer Communities Office will use the information you have shared to understand what has happened and any action that may be required in response to the incident. If you provide your contact details, the Safer Communities Office can contact you to offer confidential support, better understand your needs, and discuss available options with you.

Any personal information you provide us will be highly protected, secured and disposed of in accordance with our Privacy Policy 2017, University’s Cyber Security Policy 2019 and the University’s obligations under the State Records Act 1998 (NSW).

Whose experience are you reporting?

I am reporting my own experience.
I am reporting someone else's experience (as a witness/bystander, or disclosed to me in a personal capacity/as a support person).
I am reporting in a professional capacity (as part of my responsibilities as a University staff member, affiliate organisation or third party).

I am a:

University of Sydney staff member
University of Sydney staff member and student
Student accommodation staff member
Affiliated or third-party provider staff member
Other member of the University community (i.e. non-staff)

I am a:

Student
Member of the public

In certain circumstances we are required by law to report incidents involving children and young people to the NSW Department of Communities and Justice. For further information on this mandatory reporting requirement, please see: Protecting our kids - Mandatory reporters

You can choose to provide your details or submit an anonymous report.

Providing your details allows the Safer Communities Office to contact you, offer confidential support and discuss available options. If you do not provide your details, the University will be unable to contact you.

I wish to provide my contact details.
I do not wish to provide my contact details.

Preferred name:

Last name

Staff ID (optional):

Student ID (optional):

Phone number:

Email address:

Preferred method of contact

Phone
Email

Please provide details:

I am:

Under 18
18 and above

I am a:

University of Sydney staff member
Student accommodation staff member
Affiliated or third-party provider staff member
Other member of the University community (i.e. non-staff)

I am a:

Student
Member of the public

You can choose to provide your details or submit anonymously.

Providing your details allows the Safer Communities Office to contact you, offer confidential support and discuss available options. If you do not provide your details, the University will be unable to contact you.

Your full name:

Your University email address:

Your email address:

Your best contact number:

I wish to disclose anonymously.

Please provide details:

Please confirm the type of report you are making:

Reporting an incident in my capacity as a staff member receiving the disclosure
Reporting an incident on behalf of a University-owned and operated/third-party operated accommodation provider
Reporting an incident on behalf of Campus Security
Reporting an incident on behalf of another University business area
Other

Please provide specific details:

Are you reporting on behalf of a placement provider?

Yes
No

Please provide the full details of the placement provider, including their location:

Please provide your details below.

Your full name:

Your institutional email address:

Your best contact number:

Your Internal Reference Number (if applicable):

Is this a disclosure or a complaint?

Disclosure
Complaint

Your Internal Referral ID (i.e. system reference number):

Is this a referral or a consult?

Referral (affected person has provided consent to be contacted by Safer Communities for support)
Consult (affected person has NOT provided consent to be contacted by Safer Communities for support)

Please provide any additional case details and/or instructions for the Safer Communities team:

For the University to provide support and take any other appropriate action, we require the affected person's contact details. Please ensure you have the affected person's consent to share their information.

Has the affected person consented to having their personal details shared with the Safer Communities Office?

Yes
No

First name of the affected person:

Last name of the affected person:

Student ID:

Staff ID:

Phone number:

Email address:

Preferred contact method:

Phone
Email

Has the affected person consented to being contacted by the Safer Communities Office for specialist support?

Yes
No

How old is the affected person?

Under 18
18 and above
Unknown

Please provide details:

To the best of your knowledge, which of the following describes the affected person's gender identity?

Man or male
Woman or female
Non-binary
Different term
Unknown
Do not wish to disclose

Please provide details:

A reminder: forensic medical examinations for evidence collection can be undertaken up to five days after an incident of sexual assault.
Your local sexual assault service is available 24/7 and can be contacted here.

Date of the incident or most recent incident?

If unknown:

Unknown

Date of the incident or most recent incident?

If unknown:

Unknown

Did this incident occur once, or were there multiple incidents?

Single incident
Multiple incidents

Is it an ongoing situation?

Ongoing
Not ongoing

Did this incident occur once, or were there multiple incidents?

Single incident
Multiple incidents
Unknown

Is it an ongoing situation?

Ongoing
Not ongoing
Unknown

Please provide details:

Please provide details (i.e. accommodation facility and location):

Please provide details:

Please provide details (i.e. accommodation facility and location):

Please provide details:

Please provide a description of what happened. You can provide as much or as little information as you feel comfortable sharing.

Please provide a description of what happened:

Please provide details:

To the best of your knowledge, which of the following describes the gender identity of the person responsible?

Man or male
Woman or female
Non-binary
Different term
Unknown
Do not wish to disclose

Please provide details:

To the best of your knowledge, which of the following describes the gender identity of the second person responsible?

Man or male
Woman or female
Non-binary
Different term
Unknown
Do not wish to disclose

Please provide details:

To the best of your knowledge, which of the following describes the gender identity of the third person responsible?

Man or male
Woman or female
Non-binary
Different term
Unknown
Do not wish to disclose

Please provide details:

To the best of your knowledge, which of the following describes the gender identity of the fourth person responsible?

Man or male
Woman or female
Non-binary
Different term
Unknown
Do not wish to disclose

Please provide any other identifying information about the person/s responsible:

Privacy Collection Notice

Any personal information you give us will be highly protected, secured and disposed of in accordance with our Privacy Policy 2017, University’s Cyber Security Policy 2019 and the University’s obligations under the State Records Act 1998 (NSW). We will not share personal information about you or anyone named in your report unless the person has consented, we are required by law to do so (such as the NSW Police), or there is a serious or ongoing risk of harm to the health or safety of any person. To ensure our compliance with the National Higher Education Code to Prevent and Respond to Gender-based Violence, strictly de-identified information about the incident you are reporting may be used in analysis and reporting.

For more information about how the University handles personal information, how individuals can request to access or correct the personal information we hold about them, and who to contact if they have a privacy enquiry or complaint, please see our webpage: Privacy at the University - The University of Sydney.

You have reached the end of this form. Once you click the Submit button below, your form will be sent to the Safer Communities Office who will contact you within 2 business days. Please note that if you have chosen to submit an anonymous report, we will have no means to contact you.

To amend or withdraw your form after it has been submitted, please contact the Safer Communities Office on +61 2 8627 6808 or at safer-communities.officer@sydney.edu.au